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Based on interview and record review, the Governing Body (GB) failed to provide adequate oversight to ensure safe and effective patient care. This occurred when:

1. The GB did not ensure the necessary equipment and/or supplies were safe, routinely checked, and remove from the patient care area after the expiration date. (Refer to A-0144)

2. The GB did not ensure patients' nutrition, weight management and wound care treatment were supervised, managed, and evaluated appropriately. (Refer to A-0395 and A-0397)

3. The GB did not ensure the critical test results were reported in a timely manner to physicians responsible for patient's care. (Refer to A-0398)

4. The GB did not ensure the emergency response was provided in accordance with the Advanced Cardiac Life Support (ACLS-a set of clinical guides for the urgent treatment of heart emergencies). (Refer to A-0398)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, and record review, the hospital failed to maintain an effective and on-going Quality Assessment and Performance Improvement (QAPI) program by failing to ensure the following:

1. The QAPI did not ensure the necessary equipment and/or supplies were safe, routinely checked, and remove from the patient care area after the expiration date. (Refer to A-0144)

2. The QAPI did not ensure patients' nutrition, weight management and wound care treatment were supervised, managed, and evaluated appropriately. (Refer to A-0395 and A-0397)

3. The QAPI did not ensure the critical test results were reported in a timely manner to physicians responsible for patient's care. (Refer to A-0398)

4. The QAPI did not ensure the emergency response was provided in accordance with the Advanced Cardiac Life Support (ACLS-a set of clinical guides for the urgent treatment of heart emergencies). (Refer to A-0398)

5. The QAPI did not ensure patients were assessed before and/or after medication administration. (Refer to A-0405)

6. The QAPI did not ensure the medication was given as ordered and within the acceptable standards of practice. (Refer to A-0405 and A-0410)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to maintain an organized Nursing Services, when:

1. For one of 31 sampled patients (Patient 2), a Weight was not obtained on admission or weekly per the Physician's order for a total of 20 days. (Refer to A-0395)

2. For three of 31 sampled patients (Patients 2, 4, and 11), the Physician was not notified of significant weight changes and a Change of Condition (COC) reassessment was not initiated. (Refer to A-0395)

3. For four of 31 sampled patients (Patient 3, 4, 14, and 19), the nursing staff did not consistently assess a pressure ulcer (PU-an injury to skin and underlying tissue resulting from prolonged pressure on the skin) every shift and/or perform wound dressing change as ordered. (Refer to A-0395)

4. For four of 31 sampled patients (Patient 3, 14, 19, and 30), the nursing staff did not document repositioning of patients every two hours. (Refer to A-0397)

5. For two of 31 sampled patients (Patient 4, and 19), the nursing staff did not ensure patients' head of the bed (HOB) raise at least 30 degrees while on a continuous tube feeding (a medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake). (Refer to A-0397)

6. For one of 31 sampled patients (Patient 4), the nursing staff did not administer a continue tube feeding in accordance with the physician's order. (Refer to A-0397)

7. For one of 31 sampled patients (Patient 1), the nursing staff did not notify the ordering physician of the critical result of the abdominal x-ray (KUB-an image of the inside of the abdominal area) in a timely manner. (Refer to A-0398)

8. For one of 31 sampled patients (Patient 1), the nursing staff did not follow the Advanced Cardiac Life Support (ACLS-a set of clinical guides for the urgent treatment of heart emergencies) guideline during the cardiopulmonary resuscitation (CPR-emergency procedure as an effort to restore blood circulation in a person when heart stop). (Refer to A-0398)

9. For one of 31 sampled patients (Patient 5), the nursing staff administered Hydromorphone (Dilaudid-medication to treat pain) faster than the recommended administration rate. (Refer to A-0405)

10. For one of 31 sampled patients (Patient 30), the nursing staff administered Haloperidol (Haldol-medication to treat mental disorder) with a narrow time between two doses. (Refer to A-0405)

11. For two of 31 sampled patients (Patient 12 and 13), the nursing staff did not assess patients' condition as ordered before and/or after as needed (PRN) medications administration. (Refer to A-0405)

12. For two of 31 sampled patients (Patient 5 and 13), the nursing staff administered Dilaudid and Hydrocodone (medication to treat pain) medications for a wrong pain indication level as ordered without any physician's notification for other alternative medications). (Refer to A-0405)

13. For two of 31 sampled patients (Patient 5 and 20), the nursing staff administered Dilaudid and Lorazepam (medication to treat anxiety) for a wrong indication not ordered by the physician. (Refer to A-0405)

14. For two of 31 sampled patients (Patient 1 and 4), the nursing staff did not monitor patients' blood pressure after intravenous (IV-into the vein) Norepinephrine (Levophed-medication to increase blood pressure) were given. (Refer to A-0410)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure safe and quality nursing care in a safe environment.

Based on observation and interview, the facility failed to ensure the necessary equipment and/or supplies to immediately respond to potential adverse events were safe and readily available for use for a universe of 67 patients when:

1. In Unit 200, one (1) expired 300 milliliter (unit of measurement) canister (with Gel) for [Brand name] therapy system (portable negative pressure wound therapy system designed for mobile patients) was available in the patient care area.

2. In Unit 300, one (1) crash cart (an emergency cart containing equipment, supplies, and medication used during a medical emergency) with a numbered seal used by the pharmacy (green lock number) was different from what was documented on the crash cart log and was not checked for integrity.

3. In Unit 200, one (1) expired crash cart intubation (a procedure involving the insertion of a tube into the throat to help with breathing) bag was not checked for the integrity of its contents.

These failures had the potential to result in unsafe care provided to patients by the potential use of supplies, equipment, and inconsistent lock controls with dates beyond the use date (expired) which could potentially cause infection, injuries, and/or death to medically compromised patients.



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1. During a concurrent observation and interview, on March 28, 2022, at 09:35 AM, with the Director of Nursing 1 (DON 1), in the medication room of Unit 200, one (1) 300 ml canister (with Gel) for [Brand Name] therapy system was found with the expiration date of January 31, 2021. The DON 1 verified one (1) 300 ml canister (with Gel) for [Brand Name] therapy system with the expiration date of January 31, 2021.

During an interview, on March 29, 2022, at 10:32 AM, with the Director of Quality Management (DQM), she stated there is no policy to be found for the expired supplies.

2. During a concurrent observation and interview, on March 28, 2022, at 02:10 PM, with the Senior Clinical Operation Registered Nurse (SCON), in Unit 300, the "Crash Cart Check List" was observed with the green lock number documented as "0224202". The crash cart was observed with the green lock number as "9513722". The SCON verified the green lock number on the "Crash Cart Check List" was different from the actual green lock number on the crash cart.

During an interview, on March 28, 2022, at 2:27 PM, with Registered Nurse 4 (RN 4), RN 4 stated, she checked the crash cart this morning and the green lock number was "0224202".

During a concurrent observation and interview, on March 28, 2022, at 2:35 PM, with the Director of Pharmacy (DOP), in Unit 300, the Pharmacy Crash Cart Log was observed with the green lock number as "0224202". The DOP stated, Unit 300 did not call pharmacy today to ask for a crash cart replacement.

During an interview, on March 28, 2022, at 2:50 PM, with Respiratory Care Practitioner 2 (RCP 2), RCP 2 stated, he accidentally broke the green lock on the crash cart, he asked the supervisor for a lock replacement. RCP 2 stated, he replaced the broken green lock without notifying to the pharmacy.

During a review of the facility's policy and procedure titled, "CORE: Emergency medications" release date June 2021, the Policy and Procedure indicated,

"Purpose-This policy establishes guidelines for emergency medications and/or supplies, if any, are readily available, controlled, and secured.

Policy-The policy of [Hospital Name] is to ensure the following ...

3.When emergency medications or supplies are used, the hospital replaces them as soon as possible to maintain a full stock. The final seal used by pharmacy shall be a numbered seal with a distinctive color that is supplied by the pharmacy only ..."


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3. During an observation, on March 28, 2022, at 11:15 AM, with the DON 1, in Unit 200, the crash cart intubation bag checklist indicated the bag was last checked on September 3, 2021. On further review of the intubation bag checklist, one (1) endotracheal tube (ET tube-a tube placed by mouth during a respiratory emergency) size 8.0 had an expiration date of February 7, 2022. An ET tube size 8.0 was found in the intubation bag with the expiration date of February 7, 2022.

During a concurrent observation and interview, on March 28, 2022, at 11:28 AM, with RCP 1, in Unit 200, the crash cart intubation bag was observed. RCP 1 confirmed an ET tube size 8.0 contained in the intubation bag was expired. RCP 1 stated the intubation bag is supposed to be checked monthly by the respiratory department.

During an interview, on March 28, 2022, at 1:20 PM, with the Director of RCP (DRCP), in Unit 200, the DRCP stated the intubation bag for the crash cart was last checked on September 2021. The DRCP further stated the facility did not have a system in place to remind staff to check the contents of the bag.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Emergency Medications," dated June 2021, the P&P indicated,

"Purpose
This policy establishes guidelines for emergency medications and/or supplies, if any, are readily available, controlled, and secured.
Policy
The policy of Kindred Hospital is to ensure the following:
1. Emergency drugs and supplies, for use in medical emergencies only, shall be immediately available at each patient care unit or service area ....
Procedure
1. Documentation
a. The contents of the emergency cart should follow current Advanced Cardiac Life Support (ACLS-a set of clinical guides for the urgent treatment of heart emergencies) guidelines .....
c. Patient care units are responsible for checking the integrity of the emergency cart at least daily. This check should include: .....
iii. The integrity of the seal on cart. Log should include number of seal and if broken, reason for breaking
iv. Expiration date on labels for drugs and equipment/supplies .....
2. Minimum Contents of Cart
a. Binder with necessary documents (i.e. Code sheets, current ACLS guidelines)
b. Approved medications
c. Back board
d. Flashlight
e. Defibrillator and pads
f. Intubation box .... "

Based on interview and record review, the facility failed to ensure the nursing staff supervise and evaluate the nursing care for patients' nutrition status and wound assessment when:

1. A Weight was not obtained on admission or weekly per the Physician's order for a total of 20 days, for one of 31 sampled patients (Patient 2).

2. The Physician was not notified of significant weight changes and a Change of Condition (COC) reassessment was not initiated for three for 31 sampled patients (Patients 2, 4, and 11).

These failures could compromise Patient 2, 4, and 11's nutritional status which could lead to medical complications.

3. The nursing staff did not consistently assess a pressure ulcer (PU-an injury to skin and underlying tissue resulting from prolonged pressure on the skin) every shift and/or perform wound dressing change as ordered for four of 31 sampled patients (Patient 3, 4, 14, and 19).

This failure resulted in inconsistency of wound treatment and contributed to the worsening of the wound and had the potential to jeopardize patients' health condition and prolonged hospitalization.

Findings:

1. A review of Patient 2's "History and Physical," dated February 1, 2021, on March 28, 2022. Patient 2 was admitted to the facility with diagnoses which included acute hypoxemic respiratory failure (lack of adequate oxygen in the blood) requiring mechanical ventilation (use of a machine called a ventilator to provide artificial ventilation), status post tracheotomy (surgical procedure which creates a direct airway to the trachea), severe motor vehicle accident versus stroke, facial fracture with severe traumatic encephalopathy (a disease which affects the functioning of the brain), moderate to severe protein deficiency malnutrition (an imbalance between the supply of protein and energy), and traumatic brain injury (brain dysfunction caused by an outside force).

A review of Patient's 2 "Physician orders," dated February 2, 2021, showed, monitor weight for improvement: start February 2, 2021.

During a concurrent interview and record review, on March 28, 2022, at 9:45 AM, with the Registered Dietitian (RD), Patient 2's medical record, was reviewed. The RD stated he used the admission weight of 118 pounds (lbs.) entered in the computer system on March 2, 2021, by nursing for his initial assessment dated February 2, 2021. The RD felt the admission weight was not an accurate weight because that was Patient 2's weight taken from the previous facility. The RD stated Patient 2's weight should have been obtained on admission and continued weekly. The RD further stated he had no choice but to use the documented admission weight as it was the only weight he had. The RD stated Patient 2 was non-verbal and her family stated her usual body weight was about 105 lbs. A reassessment was completed by the RD on February 9, 2021. The documented admission weight of 118 lbs. was again used to assess Patient 2. The next documented weight for Patient 2 was 86 lbs. On February 2, 2021, a significant severe weight loss of 32 lbs., 27% in 20 days. A nutrition assessment was completed by the RD on February 24, 2021, which showed, "Patient with large weight loss since admit weight, noted patient admit weight seemed high form visual examination of the patient, but likely patient with some weight loss since admit, no weekly weights had been done previously since admit weight." The RD confirmed weekly weights were not obtained from 2/2/21 to 2/22/21, a 20-day period for Patient 2.

A follow-up concurrent and record review, on March 29, 2022, at 9 AM, with Registered Nurse 3 (RN 3) and the Director of Nursing 1 (DON 1), Patient 2's medical record, was reviewed. RN 3 stated patient weights are obtained on admission typically using the bed scale. The admission weight and method of weighing are entered in the computer system usually by Certified Nursing Assistant (CNA). RN 3 confirmed the admission weight of 118 lbs. was entered in the computer system on February 2, 2021, by the RD. The entry did not show what method was used to weigh Patient 2. RN 3 further stated she was not sure why the RD entered Patient 2's weight in the computer system. The DON 1 stated patients in the Intensive Care Unit (ICU) are weighed weekly per protocol. Review of the documented weights entered in the computer system for Patient 2 showed the first weekly weight was taken on February 22, 2021, 21 days after admission. The DON 1 confirmed Patient 2 had not been weighed weekly as ordered.

A follow-up interview, on March 29, 2022, at 11:47 AM, with the RD regarding the admission weight for Patient 2. The RD confirmed he entered the admission weight for Patient 2 in the computer system. The RD stated the admission weight entered in the computer system for Patient 2 was not a physical weight. The RD used the weight from the hospital records for Patient 2 because he needed a weight to complete the nutritional assessment.

A review of the facility policy and procedure (P&P) titled, "CORE: Weight Management," release date June 2021, showed, "This procedure establishes guidelines for measurement of weight. Weight is an anthropometric measurement used in conjunction with other information to calculate estimated energy, protein, and fluid needs ... Weight change over time is an important indicator of nutritional status and fluid status. Policy: 1. The policy of Kindred Hospital is to ensure the proper measurement of patient's weights. Self-reported weight and weights from another facility are not use in lieu of actually weighing the patient ...2. ...Weight measurement is scheduled as follows: a. Weight within 24 hours of admission, b. Weekly thereafter ...6. Change in weight gain or loss are addressed in the nutrition assessment and the patient's care plan as applicable. 9.e Bed scales ...2. Standard items as part of the weight measurement include a. one flat sheet, b. one cover sheet, c. one pillow with pillowcase, d. one blanket e. patient night gown, f. one under pad.

2a. During a concurrent interview and record review, on March 29, 2022, at 9 AM, with RN 3 and the DON 1, Patient 2's documented weights, was conducted. The documented admission weight for Patient 2 on February 2, 2021, was 118 lbs. entered in the computer system by the RD with no method of weighing documented. The first documented weekly weight for Patient 2 was 86 lbs. on February 22, 2021, using a sling scale. This was a 32 lb., 27% significant severe weight loss in 20 days. RN 3 stated she would compare the current weight with the previous weekly weight in the computer system and notify the Physician of any significant change. RN 3 confirmed Patient 2's weight on February 22, 2021, was a significant change. RN 3 stated she would make sure the current weight was accurate by zeroing the bed again and reweighing the patient. The DON 1 confirmed there was no documentation which showed the Physician was notified of Patient 2's significant severe weight loss of 32 lbs., 27% in 20 days. On March 1, 2021, Patient 2's documented weight was 85 lbs. using a bed scale, on March 8, 2021, Patient 2's documented weight was 74 lbs. using a bed scale; an 11 lb., 12.9% significant severe weight loss in one week. On March 15, 2021, Patient 2's documented weight was 78 lbs. (no method of weighing was documented), on March 17, 2021, Patient 2's documented weight using a bed scale was 89.5 lbs., an 11.5 lb., 12.8% significant severe weight gain in two days. On March 24, 2021, Patient 2's documented weight (no method of weighing was documented) was 114 lbs., a 24.5 lb., 21.4% significant severe weight gain in one week. On April 5, 2021, Patient 2's documented weight using a bed scale was 118 lbs., on April 6, 2021, Patient 2's documented weight (no method of weighing documented) was 90 lbs., a 28 lb., 23.7% significant severe weight loss in one day. The DON 1 stated a significant weight change was considered a Change of Condition (COC) and should be care planned per the COC pathway in the computer system.

During an interview, on March 29, 2022, at 11:20 AM, with the DON 1, the DON 1 confirmed the Physician was not notified regarding the significant weight changes nor was a COC reassessment initiated for Patient 2.

2b. A review of Patient 4's H&P, dated January 19, 2022, on March 28, 2022, the H&P indicated, Patient 4 was admitted to the facility with diagnoses which included Respiratory failure (blood lacks adequate oxygen), sepsis/empyema (pus in pleural cavity), and mitral valve endocarditis (inflammation of the heart valve) and End-stage renal (kidney) disease on dialysis.

During a concurrent interview and record review, on March 29, 2022, at 9:30 AM, with RN 3 and the DON 1, Patient 4's documented weights, was conducted. On February 25, 2022, Patient 4's documented weight using a bed scale was 216.4 lbs., on February 26, 2022, Patient 4's documented weight using a bed scale was 240 lbs., a 23.6 lb., 9.8% significant severe weight gain in one day. On March 5, 2022, Patient 4's documented weight (no method of weighing documented) was 200.86 lbs., on March 7, 2022, Patient 4's documented weight using a bed scale was 118.5 lbs., an 82.3 lb., 41% severe significant weight loss in two days. On March 13, 2022, at 5:45 AM, Patient 4's documented weight was 106 lbs. using a bed scale and on March 13, 2022, at 10:20 PM, Patient 4's documented weight using a bed scale was 234 lbs., a 128 lb., 45.7% severe significant weight gain in less than 24 hours. On March 16, 2022, Patient 4's documented weight was 266 lbs. using a bed scale and on March 17, 2022, Patient 4's documented weight was 167.6 lbs., a 98.4 lb., 36.9% significant severe weight loss in one day. RN 3 stated if a patient had that large of a weight change the CNA should notify the RN.

A follow-up interview, on March 29, 2022, at 11:20 AM, with the DON 1, the DON 1 confirmed the Physician was not notified regarding the significant weight changes nor was a COC reassessment initiated for Patient 4.

During an interview, on March 29, 2022, at 3:05 PM, with Physician 2 (Phys 2), when asked if it was possible for a dialysis patient to lose 82 lbs. in two days, Phys 2 stated it was not possible. The Phys 2 stated he should be notified of any significant weight change.

2c. A review of Patient 11's H&P, dated March 19, 2022, on March 28, 2022, indicated, Patient 11 was admitted to the facility with diagnoses including basal ganglia intracranial hemorrhage (bleeding of the brain), hydrocephalus (fluid accumulation in the brain) status post VP shunt placement (ventriculoperitoneal shunt to treat excess fluid in the brain), respiratory failure and acute renal (kidney) failure on dialysis.

During a concurrent interview and record review, on March 29, 2022, at 9:45 AM, with RN 3 and the DON 1, Patient 11's documented weights, was conducted. On March 27, 2022, Patient 11's documented weight using a bed scale at 3:46 p.m. was 151.95. On March 27, 2022, at 8:50 PM, Patient 11's documented weight using a bed scale was 161.5 lbs., a 9.5 lb., 5.9% significant weight gain in less than six hours. The DON 1 stated the CNA should document she notified the nurse of the weight discrepancy. The DON 1 stated he was concerned nobody had acknowledged the discrepancy in patient weights. He stated, "What if it isn't a scale problem?" RN 3 added a dialysis patient could have rapid fluid gain and she would expect the Physician be notified of a significant weight change.

A follow-up interview, on March 29, 2022, at 11:20 AM, with the DON 1, the DON 1 confirmed the Physician was not notified regarding the significant weight change nor was a COC reassessment initiated for Patient 11.

A follow-up interview, on March 29, 2022, at 3:05 PM, with Phys 2, when asked if it was possible for a dialysis patient to gain 9.5 lbs. in less than six hours, Phys 2 stated it was not possible. The Phys 2 stated he should be notified of any significant weight change.

Review of the facility policy and procedure titled, "CORE: Interdisciplinary Assessment and Re-Assessment" with a release date of 6/21 showed, under the Policy section, 2. The goal of the assessment/reassessment process is to provide an interdisciplinary approach for the assessment and ongoing reassessment of individual patient care needs and for planning and implementing patient specific interventions. Under the Procedure section: The assessment framework is structured around two components: initial screening and assessment/reassessment of each patient as appropriate to the clinical discipline and individual patient condition changes. 3. Nursing department a. An admission assessment is performed by a Registered Nurse and is recorded in the patient medical record, within 12 hours of admission. This assessment is based upon actual observation, patient/family interview, patient medical records accompanying the patient from the referral facility ... d. The admitting RN will screen each patient during the initial assessment process to identify those patients requiring further specialized interventions, and /or possible referral to and assessment by other appropriate disciplines. ...ii. Nutritional status. g. Patient reassessment is based on but not limited to the following: ii. To respond to a significant changed in status and/or diagnosis or condition. 4. Nutrition Services a. In collaboration with the patient, patient's family member or responsible party, and interdisciplinary team, the Registered Dietitian utilizes the Nutrition Care Process to: i. Assess nutritional status ...d. The registered dietitian identifies patients needing further monitoring/evaluation. V. Having a significant unintentional weight change ...14. Reporting/Notification of a Change in Condition a. An acute change of condition is a clinically important change from a patient's established and documented baseline in physical ...domains. C. Changes in condition of the patient are determined by assessments using clinical parameters, current and past documented medical condition ...15. Notification Responsibilities When an Assessment Reveals a Change or Suspected Change in Condition a. The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response. e. Document change of condition, notification and interventions in the medical record.


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3a. During a review of Patient 3's "History and Physical (H&P)," dated November 20, 2021, the H&P indicated, Patient 3 was admitted to the facility with diagnoses including status post fall, head trauma, cardiac arrest (abrupt loss of heart function), and respiratory failure (a condition when lungs cannot get enough oxygen).

A review of Patient 3's "Weekly Wound Care," dated February 11, 2022, at 6:42 PM, indicated, a deep tissue injury (DTI-a maroon or purplish discoloration of intact skin) to the right trochanter (hip bone) had progressed to an unstageable (full thickness tissue loss in which the base of wound covered by slough [yellow] and/or eschar [brown or black] in the wound bed) PU.

During an interview, on March 29, 2022, at 10:12 AM, in the conference room, with Registered Nurse 3 (RN 3), RN 3 stated, the wound assessment should be completed every shift. RN 3 further stated, if the wound was covered and did not need to be changed, the staff should document the appearance and status of the dressing such as dry and intact. RN 3 stated, if there was no documentation, "it's not done."

A follow-up concurrent interview and record review, on March 29, 2022, at 4:16 PM, in the Director of Quality Management (DQM)'s office, with the DQM and the Chief Operating Officer (COO), Patient 3's "Impaired skin/tissue integrity: Nurses notes," dated February 6, 2022, through February 16, 2022, were reviewed. There was no documentation of wound dressing assessment for integrity and appearance for the following shift:

February 7, 2022: night shift (7 PM to 7 AM)

February 8, 2022: night shift

February 12, 2022: night shift

The COO stated, the nursing staff should assess the wound dressing for integrity every shift. The COO confirmed, the nursing staff did not follow the facility's P&P for the wound dressing assessment.

A review of the facility's policies and procedures (P&P) titled, "Core: Skin & Wound Care Program Overview", release date June 2020, indicated as follow:

"Purpose: this policy establishes guidelines to provide individuals with high-quality, cost-effective skin and wound care services that result in excellent clinical outcomes ...

Policy: The policy of [Hospital Name] is to ensure the following: ...

6. Documentation standards used to measure quality outcomes:

a. Braden Scale on admission, then daily, including day of discharge.

b. A AWAT assessment at time of admission, weekly, change in wound status, new wounds, and discharge (patient with wounds).

H-PC 10-002 CORE: Wound Care Team Assessment

c. Assessment of wound characteristics via reassessment pathway completed with each routine dressing change.

d. Non-scheduled dressing changes will be assessed every shift for integrity and appearance.

e. Skin assessment/inspection at time of admission and each shift

f. Support surfaces and other preventive devices ..."

3b. During a review of Patient 4's H&P," dated January 20, 2022, the H&P indicated, Patient 4 was admitted into the facility with diagnoses including respiratory failure, and end stage renal disease (ESRD-a condition that kidney lost function) on hemodialysis (a process using a special machine to clean blood for patient with kidney problem).

A review of Patient 4's "Weekly Wound Care," dated March 18, 2022, at 4:35 PM, indicated, Patient 4 had a stage 4 (full thickness skin loss with extensive destruction to tissue, muscle, or bone) PU to sacralcoccyx (tailbone).

During an interview, on March 28, 2022, at 2:30 PM, in the conference room, with the Director of Nursing 1 (DON 1), the DON 1 stated, the nursing staff needed to assess the integrity of wound dressing every shift, change the dressing as needed (PRN), and document as "executed" on each dressing assessment to indicate the wound assessment.

During an interview, on March 29, 2022, at 10:12 AM, in the conference room, with RN 3, RN 3 stated, the wound assessment should be completed every shift. RN 3 further stated, if the wound was covered and did not need to be changed, the staff should document the appearance and status of the dressing such as dry and intact. RN 3 stated, if there was no documentation, "it's not done."

A follow-up concurrent interview and record review, on March 29, 2022, at 10:15 AM, with RN 3, Patient 4's "Impaired skin/tissue integrity: Nurses notes," dated March 21, 2022, through March 25, 2022, were reviewed. The wound dressing assessment was documented as "not done, cancel this execution" for the following shift:

March 22, 2022, at 10:21 PM

March 23, 2022, at 10:12 PM

March 24, 2022, at 4:18 PM

March 24, 2022, at 11:23 PM

RN 3 stated, "not done, cancel this execution" meant the wound and the integrity of wound dressing were not assessed by the nursing staff. RN 3 confirmed, the nursing staff did not follow the facility's P&P for the wound dressing assessment.

A review of the facility's P&P titled, "Core: Skin & Wound Care Program Overview", release date June 2020, indicated as follow:

"Purpose: this policy establishes guidelines to provide individuals with high-quality, cost-effective skin and wound care services that result in excellent clinical outcomes ...

Policy: The policy of [Hospital Name] is to ensure the following: ...

6. Documentation standards used to measure quality outcomes:

a. Braden Scale on admission, then daily, including day of discharge.

b. A AWAT assessment at time of admission, weekly, change in wound status, new wounds, and discharge (patient with wounds).

H-PC 10-002 CORE: Wound Care Team Assessment

c. Assessment of wound characteristics via reassessment pathway completed with each routine dressing change.

d. Non-scheduled dressing changes will be assessed every shift for integrity and appearance.

e. Skin assessment/inspection at time of admission and each shift

f. Support surfaces and other preventive devices ..."


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3c. A review of Patient 14's "History and Physical (H&P)," dated March 17, 2022, indicated Patient 14 was admitted on March 16, 2022, with a diagnosis of respiratory failure (serious condition of difficulty breathing on one's own), status post motor vehicle accident with multiple traumatic injuries, including liver and spleen injuries, multiple fractures, chronic respiratory failure, status post tracheostomy (trach - a tube placed into the trachea via the neck to assist with breathing), and a complicated intraabdominal abscess (infection in the abdomen) requiring a wound VAC (VAC - vacuum assisted closure - treatment that helps wounds heal faster).

A review of Patient 14's "Impaired skin/tissue integrity: Nurse Notes," dated March 18, 2022, indicated, Patient 14 had a stage 3 (full thickness skin loss injury) PU to the left trochanter (upper outer thigh and hip area of the body) present on admission.

During a concurrent interview and record review, on March 29, 2022, at 3:39 PM, in the conference room, with the Director of Nursing 1 (DON 1), Patient 14's "Impaired skin/tissue integrity: Nurses notes," dated March 18, 2022, through March 20, 2022, were reviewed. There was no assessment of the left trochanter pressure injury during the following dates and times:

On March 18, 2022: night shift (7 PM to 7 AM)

On March 19, 2022: night shift

On March 20, 2022: day shift (7 AM to 7 PM)

The DON 1 stated, the nursing staff should assess wounds every shift. The DON 1 confirmed, he was not able to find any documentation to indicate the nursing staff completed the wound assessment every shift.

A review of the facility's policies and procedures (P&P) titled, "Core: Skin & Wound Care Program Overview", release date June 2020, indicated the following:

"Purpose: this policy establishes guidelines to provide individuals with high-quality, cost-effective skin and wound care services that result in excellent clinical outcomes ...

Policy: The policy of [Hospital Name] is to ensure the following: ...

6. Documentation standards used to measure quality outcomes:

a. Braden Scale on admission, then daily, including day of discharge.

b. A AWAT assessment at time of admission, weekly, change in wound status, new wounds, and discharge (patient with wounds).

H-PC 10-002 CORE: Wound Care Team Assessment

c. Assessment of wound characteristics via reassessment pathway completed with each routine dressing change.

d. Non-scheduled dressing changes will be assessed every shift for integrity and appearance.

e. Skin assessment/inspection at time of admission and each shift

f. Support surfaces and other preventive devices ..."

3d. A review of Patient 19's Face Sheet, indicated Patient 19 was admitted on February 15, 2022, with a diagnosis of respiratory failure.

During a record review, on March 30, 2022, at 11:00 AM, in the DON 1's office, with the DON 1, Patient 19's "Weekly Wound Care", dated February 16, 2022, at 2:54 PM, was reviewed. The "Weekly Wound Care" indicated Patient 19 had multiple skin problems present on admission, including diabetic ulcers (open sores from a condition of uncontrolled blood sugar) and an unstageable PU to the sacrococcyx bilateral buttocks.

A review of Patient 19's "Physician Orders," for wound care, dated February 16, 2022, at 4:48 PM, indicated wound care and dressing changes were to be done by the wound care team every 3 (three) days, and the floor nurses are to assess the wound dressing every shift and change if soiled or displaced.

During a follow up concurrent interview and record review, on March 30, 2022, at 11:10 AM, with the DON 1, Patient 19's "Impaired Skin/Tissue Integrity: Nurses notes," dated February 16, 2022, through March 2, 2022, were reviewed. The "Impaired Skin/Tissue Integrity: Nurses notes" indicated, the wound dressings were completed on the following dates:

On February 16, 2022: dressing changed

On February 23, 2022: dressing changed (7 days after the previous dressing change)

On March 2, 2022: dressing changed (7 days after the previous dressing change)

The DON 1 was not able to find documentation showing the dressing changes were completed every three days. The DON 1 confirmed dressing changes were not completed every three days as ordered.

A review of the facility's policies and procedures (P&P) titled, "Core: Skin & Wound Care Program Overview", release date June 2020, indicated the following:

"Purpose: this policy establishes guidelines to provide individuals with high-quality, cost-effective skin and wound care services that result in excellent clinical outcomes ...

Policy: The policy of [Hospital Name] is to ensure the following: ...

6. Documentation standards used to measure quality outcomes:

a. Braden Scale on admission, then daily, including day of discharge.

b. A AWAT assessment at time of admission, weekly, change in wound status, new wounds, and discharge (patient with wounds).

H-PC 10-002 CORE: Wound Care Team Assessment

c. Assessment of wound characteristics via reassessment pathway completed with each routine dressing change.

d. Non-scheduled dressing changes will be assessed every shift for integrity and appearance.

e. Skin assessment/inspection at time of admission and each shift

f. Support surfaces and other preventive devices ..."

Based on observation, interview, and record review, the facility failed to ensure the nursing staff provided care for patients in accordance with the patients' need when:

1. The nursing staff did not document repositioning of patients every two hours for four of 31 sampled patients (Patient 3, 14, 19, and 30).

This failure had the potential to result in pressure injury (PI-an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and contribute to the worsening of PI which would jeopardize patient's health condition and prolonged hospitalization.

2. The nursing staff did not administer a continue tube feeding in accordance with the physician's order for one of 31 sampled patients (Patient 4).

3. The nursing staff did not ensure patients' head of the bed (HOB) raise at least 30 degrees while on a continuous tube feeding (a medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) for two of 31 sampled patients (Patient 4, and 19).

These failures had the potential to cause aspiration (food enters to airway instead of stomach or choking) and malnutrition (body did not have enough food or nutrients) that negatively impact Patient A's health and safety, which could prolong hospitalization.

Findings:

1a. During a review of Patient 3's "History and Physical (H&P)," dated November 20, 2021, the H&P indicated, Patient 3 was admitted to the facility with diagnoses including status post fall, head trauma, cardiac arrest (abrupt loss of heart function), and respiratory failure (a condition when lungs cannot get enough oxygen).

During a review of Patient 3's "Nursing Notes," for Reposition, dated February 11, 2022, through February 15, 2022, the "Nursing Notes," for Reposition indicated, the nursing staff did not reposition Patient 3 every two hours on the following time:

February 11, 2022, from 6 AM through February 15, 2022, at 10 AM

During an interview, on March 29, 2022, at 10:18 AM, in the conference room, with Registered Nurse 3 (RN 3), RN 3 stated, patients should have been repositioned every two hours. RN 3 further stated, the nursing staff should renew the repositioning ordered when the order was expired. RN 3 stated, if there was no documentation, "it's not done."

A following-up interview, on March 29, 2022, at 10:22 AM, in the conference room, with the Director of Nursing 1 (DON 1), the DON 1 stated, he was aware of the repositioning order problem. The DON 1 confirmed, Patient 3 was not repositioned every two hours.

A review of the facility P&P titled, "Core: Clinical Guidelines for Pressure Injury," release date June 2019, the P&P indicated as follow:

"Purpose: this policy and procedures establishes guidelines for the RNs role in the prevention and treatment of pressure injuries based on Braden Risk score and subscales.

Policy ...
5. Standard interventions for all patients can include but not limited to:

a. High specification support surface

b. Skin and wound assessment

c. Repositioning orders (minimum every (q) two (2) hours turns)

d. Wound care consult

e. Nutritional consult

f. Decrease or eliminate friction and shear forces

g. Incontinence management

h. Consider bariatric patients and risk for injury as a result of high adipose tissue concentration (i.g. non body prominences, tissue pressure across buttocks, etc).

i. Repositioning ..."

1b. A review of Patient 14's H&P, dated March 17, 2022, indicated Patient 14 was admitted on March 16, 2022, with a diagnosis of respiratory failure, status post motor vehicle accident with multiple traumatic injuries, including liver and spleen injuries, multiple fractures, chronic respiratory failure, status post tracheostomy (trach - a tube placed into the trachea via the neck to assist with breathing), and a complicated intraabdominal abscess (infection in the abdomen) requiring a wound VAC (VAC - vacuum assisted closure - treatment that helps wounds heal faster).

During a concurrent interview and record review, on March 29, 2022, at 3:50 PM, in the conference room, with the DON 1, Patient 14's "Care Plan," dated March 17, 2022, at 12:00 PM, was reviewed. The "Care Plan" indicated reposition every two hours. The DON 1 stated, the repositioning of patients is not ordered by the physician; nurses normally initiate the care plan for repositioning of patients to be turned every two hours.

During a follow-up concurrent interview and record review, with the DON 1, Patient 14's "Nurses Notes," for Repositioning, dated March 20, 2022, were reviewed. The "Nurses Notes" indicated the following:

On March 20, 2022, at 1:41 PM: turn to left

On March 20, 2022, at 6:36 PM: turn to supine

On March 20, 2022, at 10 PM: turn to left

The DON 1 verified Patient 14 was not repositioned every two hours on March 20, 2022.

A review of the facility P&P titled, "Core: Clinical Guidelines for Pressure Injury," release date June 2019, the P&P indicated as follow:

"Purpose: this policy and procedures establishes guidelines for the RNs role in the prevention and treatment of pressure injuries based on Braden Risk score and subscales.

Policy ...
5. Standard interventions for all patients can include but not limited to:

a. High specification support surface

b. Skin and wound assessment

c. Repositioning orders (minimum every (q) two (2) hours turns)

d. Wound care consult

e. Nutritional consult

f. Decrease or eliminate friction and shear forces

g. Incontinence management

h. Consider bariatric patients and risk for injury as a result of high adipose tissue concentration (i.g. non body prominences, tissue pressure across buttocks, etc).

i. Repositioning ..."

1c. A review of Patient 19's Face Sheet, indicated Patient 19 was admitted on February 15, 2022, with a diagnosis of respiratory failure.

During a concurrent interview and record review, on March 30, 2022, at 11:30 AM, in the DON 1's office, with the DON 1, Patient 19's "Nurses Notes," for Repositioning, dated March 20, 2022, were reviewed. The "Nurses Notes" indicated the following:

On March 20, 2022, at 12 PM: on supine (back)

On March 20, 2022, at 8 PM: turn to left side

The DON 1 verified the missing documentation of repositioning for Patient 19 on March 20, 2022 between 12:00 PM to 8:00 PM.

A review of the facility P&P titled, "Core: Clinical Guidelines for Pressure Injury," release date June 2019, the P&P indicated as follow:

"Purpose: this policy and procedures establishes guidelines for the RNs role in the prevention and treatment of pressure injuries based on Braden Risk score and subscales.

Policy ...
5. Standard interventions for all patients can include but not limited to:

a. High specification support surface

b. Skin and wound assessment

c. Repositioning orders (minimum every (q) two (2) hours turns)

d. Wound care consult

e. Nutritional consult

f. Decrease or eliminate friction and shear forces

g. Incontinence management

h. Consider bariatric patients and risk for injury as a result of high adipose tissue concentration (i.g. non body prominences, tissue pressure across buttocks, etc).

i. Repositioning ..."

1d. During a review of Patient 30's H&P, dated December 19, 2021, the H&P indicated, Patient 30 was admitted to the facility with diagnoses including bowel perforation (a hole in the small intestine or colon), abdominal wound, and malnutrition.

During an interview, on March 29, 2022, at 10:18 AM, in the conference room, with RN 3, RN 3 stated, patients should have been repositioned every two hours. RN 3 further stated, the nursing staff should renew the repositioning ordered when the order was expired. RN 3 stated, if there was no documentation, "it's not done."

During a concurrent interview and record review, on March 30, 2022, at 9:55 AM, in the Chief Operating Officer (COO), Patient 30's "Nursing Notes," for Reposition, dated February 1, 2022, through February 5, 2022, was reviewed. The "Nursing Notes," for Reposition indicated, the nursing staff did not reposition Patient 30 every two hours on the following time:

February 1, 2022, from 4 AM, through February 1, 2022, at 10 AM

The COO stated, she was unable to provide any documentation to justify the missing repositioning documentation. The COO confirmed, the nursing staff did not reposition Patient 30 every two hours.

A review of the facility P&P titled, "Core: Clinical Guidelines for Pressure Injury," release date June 2019, the P&P indicated as follow:

"Purpose: this policy and procedures establishes guidelines for the RNs role in the prevention and treatment of pressure injuries based on Braden Risk score and subscales.

Policy ...
5. Standard interventions for all patients can include but not limited to:

a. High specification support surface

b. Skin and wound assessment

c. Repositioning orders (minimum every (q) two (2) hours turns)

d. Wound care consult

e. Nutritional consult

f. Decrease or eliminate friction and shear forces

g. Incontinence management

h. Consider bariatric patients and risk for injury as a result of high adipose tissue concentration (i.g. non body prominences, tissue pressure across buttocks, etc).

i. Repositioning ..."

2. During a review of Patient 4's H&P, dated January 20, 2022, the H&P indicated, Patient 4 was admitted into the facility with diagnoses including respiratory failure, and ESRD on hemodialysis.

During an observation, on March 28, 2022, at 10:20 AM, in Patient 4's room, Patient 4 was observed lying in bed with a feeding pump attached to the pole located next to Patient 4's bed. The feeding pump was attached to Patient 4's G-tube set to deliver a continuous feeding at 30 ml/hr.

During an interview, on March 28, 2022, at 10:25 AM, in Patient 4's room, with RN 2, RN 2 stated, Patient 4 had high gastric residual (volume of fluid remaining in the stomach during checking for patient with tube feeding). RN 2 confirmed, Patient 4 had feeding rate infusing at 30 cc/hr and the rate would be increased once the gastric residual decreased per the physician's order.

During a concurrent interview and record review, on March 28, 2022, at 1:10 PM, in the conference room, with the COO, Patient 4's "Physician Order," for Tube feeding, dated March 24, 2022, was reviewed. The tube feeding administration rate was documented as follow:

March 26, 2022, at 8 PM: 20 ml/hr

March 28, 2022: no administration documentation

The COO stated, she was unable to provide any notification to the physician regarding the high gastric residual and the reduction of feeding administration rate.

A follow-up interview, on March 28, 2022, at 1:15 PM, with Registered Dietitian (RD), RD stated, Patient 4 had an order for a continuous tube feeding to be delivered at 55 ml/hr. RD further stated, the nursing staff needed to communicate and obtain a physician's order with the reduction of feeding rate.

During a concurrent interview and record review, on March 29, 2022, at 10:28 AM, with RN 3, Patient 4's "Physician Order," for Tube feeding, dated March 24, 2022, was reviewed. The "Physician Order" indicated; the tube feeding was ordered at 55 cc/hr. RN 3 confirmed, she did not see any order for the tube feeding rate change. RN 3 was unable to provide any physician notification of the tube feeding rate change.

A review of the facility P&P title, "Core: Administration of Enteral Nutrition," release date June 2020, indicated as follow:

"Purpose: the policy established a procedure for administration of enteral nutrition to patients meeting indication for therapy.

Policy: the policy of [Hospital Name] is to ensure the following:
1. The principal indication for enteral nutrition is a functional gastrointestinal (GI) tract with sufficient length and absorptive capacity and the inability to take nutrients through the oral route either totally or in part such as inability to swallow without chocking or aspiration, or lack of sufficient alertness for oral nutrition ...
6. The patient is monitored to identify and address any actual or potential complications related to the enteral nutrition formula, enteral nutrition infusion, or the feeding tube and the physician is notified to help evaluate and manage these complications ...

Procedure: Continuous Enteral Feeding
1. Verify the provider's order, including the patient identifiers, the prescribed route based on the enteral tube's tip location, enteral feeding device, prescribed enteral formula, administration method, volume and rate of administration, and type, volume, and frequency of water flushes ..."

3a. During a review of Patient 4's H&P," dated January 20, 2022, the H&P indicated, Patient 4 was admitted into the facility with diagnoses including respiratory failure, and end stage renal disease (ESRD-a condition that kidney lost function) on hemodialysis (a process using a special machine to clean blood for patient with kidney problem).

During an observation, on March 28, 2022, at 10:20 AM, in Patient 4's room, Patient 4 was observed lying in bed with a feeding pump (a device used to deliver food to patient via feeding tube) attached to the pole located next to Patient 4's bed. The feeding pump was attached to Patient 4's gastrostomy tube (G-tube: a tube into the stomach wall for food, fluids, and medication) and a continuous feeding was infusing at 30 milliliter per hour (ml/hr-unit flow rate).

During a concurrent observation and interview, on March 28, 2022, at 10:28 AM, in Patient 4's room, with RN 2, Patient 4 was observed with a continuous tube feeding infusing at 30 ml/hr. RN 2 stated, the HOB should be raised to at least 30 degrees for all patients with a continuous tube feeding. RN 2 further stated, the side rail of the bed would be able to provide the accurate degrees of the HOB. RN 2 was observed pushing the button on the side rail which showed the HOB was set at 24 degrees. RN 2 confirmed, the HOB was not set at least 30 degrees in accordance with the facility's protocol.
During a review of the facility's policy and procedure (P&P) titled, "CORE: Administration of Enteral Nutrition," dated June 2020, the P&P indicated the following:

"Purpose: the policy established a procedure for administration of enteral nutrition to patients meeting indication for therapy.
Policy: the policy of [Hospital Name] is to ensure the following:
1. The principal indication for enteral nutrition is a functional gastrointestinal (GI) tract with sufficient length and absorptive capacity and the inability to take nutrients through the oral route either totally or in part such as inability to swallow without chocking or aspiration, or lack of sufficient alertness for oral nutrition ...
6. The patient is monitored to identify and address any actual or potential complications related to the enteral nutrition formula, enteral nutrition infusion, or the feeding tube and the physician is notified to help evaluate and manage these complications ...
Procedure: ...
10. Assess the patient's GI status and risk for aspiration.

11. Position the patient with the head of the bed elevated to at least 30 degrees or upright in a chair to prevent aspiration. If this position is contraindicated, consider a reverse Trendelenburg (laid flat on back with feet above the head) position ..."


42294


3b. A review of Patient 19's Face Sheet, indicated Patient 19 was admitted on February 15, 2022, with a diagnosis of respiratory failure.

During a concurrent observation and interview, on March 28, 2022, at 11:02 AM, in Unit 200, with the Director of Nursing 1 (DON 1), Patient 19 was observed lying on her back and slightly to the left with the HOB flat with a continuous tube feeding infusing at 40 ml/hr. The DON 1 checked the HOB and stated, the HOB was set at 7 (seven) degrees.

During a concurrent observation and interview, on March 28, 2022, at 11:10 AM, with RN 6, Patient 19 was observed lying in bed with a continuous tube feeding. RN 6 confirmed, Patient 19's tube feeding was infusing at 40 ml/hr. RN 6 stated, the HOB should be raised above 30 degrees, or as specifically ordered, when a patient has a tube feeding infusing to prevent aspiration. RN 6 verified Patient 19's HOB was set at 15 degrees.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Administration of Enteral Nutrition," dated June 2020, the P&P indicated the following:

"Purpose: the policy established a procedure for administration of enteral nutrition to patients meeting indication for therapy.
Policy: the policy of [Hospital Name] is to ensure the following:
1. The principal indication for enteral nutrition is a functional gastrointestinal (GI) tract with sufficient length and absorptive capacity and the inability to take nutrients through the oral route either totally or in part such as inability to swallow without chocking or aspiration, or lack of sufficient alertness for oral nutrition ...
6. The patient is monitored to identify and address any actual or potential complications related to the enteral nutrition formula, enteral nutrition infusion, or the feeding tube and the physician is notified to help evaluate and manage these complications ...
Procedure: ...
10. Assess the patient's GI status and risk for aspiration.
11. Position the patient with the head of the bed elevated to at least 30 degrees or upright in a chair to prevent aspiration. If this position is contraindicated, consider a reverse Trendelenburg (laid flat on back with feet above the head) position ..."

Based on interview and record review, the facility failed to ensure the nursing staff followed their policy and procedure (P&P) in responding to the critical result and the emergency care when:

1. The nursing staff did not notify the ordering physician of the critical result of the abdominal x-ray (KUB-an image of the inside of the abdominal area) in a timely manner for one of 31 sampled patients (Patient 1).

2. The nursing staff did not follow the Advanced Cardiac Life Support (ACLS-a set of clinical guides for the urgent treatment of heart emergencies) guideline during the cardiopulmonary resuscitation (CPR-emergency procedure as an effort to restore blood circulation in a person when heart stop) for one of 31 sampled patients (Patient 1).

These failures had resulted in delayed notification to the ordering physician to initiate proper treatment that led to the emergency intervention for Patient A with the cardiopulmonary resuscitation (CPR-emergency procedure as an effort to restore blood circulation in a person when heart stop) and negatively impact Patient A's health and safety which could lead up to death.

Findings:

1. During a review of Patient 1's "History and Physical (H&P)," dated January 17, 2021, the H&P indicated, Patient 1 was admitted to the facility with diagnoses which included sepsis (severe infection), pneumonia (respiratory infection), encephalopathy (a condition of brain damage), and acute renal failure (a condition when kidneys do not work normally).

A review of Patient A's "Change of Condition," dated March 11, 2021, at 11 AM, indicated, Patient 1 pulled out his gastrostomy tube (G-tube: a tube into the stomach wall for food, fluids, and medication) and KUB was ordered after re-insertion of the G-tube.

A review of Patient A's KUB, dated March 11, 2021, at 3:06 PM, indicated, Patient A had "a large right pneumothorax (a condition when air leaks into the space between lung and chest wall, causing difficulty breathing). Recommend immediate chest examination."

During an interview, on March 29, 2022, at 10:30 AM, in the conference room, with Registered Nurse 3 (RN 3) and the Director of Nursing 1 (DON 1), RN 3 stated, the critical result should be reported to a physician within 30 minutes of receiving the report. RN 3 further stated, the nursing staff should document in the change of condition pathway and notified patient's family of the result.

A follow-up concurrent interview and record review, on March 29, 2022, at 10:35 AM, with RN 3 and the DON 1, Patient 1's "Change of Condition," dated March 11, 2021, from 4 PM through 6 PM, were reviewed. There was no documentation to indicate the critical KUB result reported to a physician or Patient 1's family. RN 3 and the DON 1 confirmed, there was no physician's notification of the critical KUB's result.

A review of Patient 1's "Change of Condition," dated March 11, 2021, at 6:45 PM, indicated, Patient 1 "heart rate dropped to 20's, no pulse noted. Code blue (a hospital emergency code) activation was called ..."

A review of Patient A's "Progress Note," dated March 11, 2021, at 10:45 PM, indicated, Physician (Phys) 1 was called to bedside after Patient A had cardiac arrest (abrupt loss of heart function). Phys 1 noted, Patient 1 had a recent KUB, after Patient 1 pulled out his feeding tube, which showed "right sided pneumothorax and recommended follow up chest studies. This was NOT completed ...Finally able to obtain chest x-ray, which still showed significant pneumothorax on the Right."

A review of the facility's P&P titled, "Core: Critical Test Results Communication," release date June 2020, indicated as follow:

"Purpose: this procedure establishes guidelines to delineate responsibility and define procedures that improves the effectiveness of communication of critical results of tests and diagnostic procedures results among care givers ...
Policy: the policy of [Hospital Name] is to ensure proper communication of critical test results (test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests). Critical results of tests and diagnostic procedures are reported to the ordering physician and/or licensed provider in a timely manner to avoid unnecessary delays in the treatment or care of the patient ...
Procedure: ...
2. The licensed nurse or nursing supervisor assigned to the patient awaiting tests results is responsible for communicating the critical results to the ordering physician or physician proxy (Licensed Independent Practitioner or on-call Physician) ..."

2. During a review of Patient 1's H&P, dated January 17, 2021, the H&P indicated, Patient A was admitted to the facility with diagnoses which included sepsis, pneumonia, encephalopathy, and acute renal failure.

During an interview, on March 28, 2022, at 9:41 AM, in the Intensive Care Unit (ICU), with the Director of Quality Management (DQM), the DQM confirmed, there was no ACLS algorithm (a simplify process to guide staff during emergency response) available for the nursing staff to follow during the emergency response, on March 23, 2021, the onsite complain investigation date.

A review of Patient 1's "Change of Condition," dated March 11, 2021, at 6:45 PM, indicated, Patient 1 "heart rate dropped to 20's, no pulse noted. Code blue was called ..."

During an interview, on March 29, 2022, at 10:40 AM, in the conference room, with RN 3 and the DON 1, RN 3 stated, the Rapid Response Team (RRT) or the code blue team would be called to bedside when patient was observed to have any change in condition such as decreased in heart rate. RN 3 further stated, the team would follow ACLS guideline as soon as emergency response activates such as initiate CPR and check heart rate (HR) and rhythm. RN 3 stated, the HR and rhythm should be checked every two minutes (mins), and Epinephrine (emergency medication to increase HR and blood pressure [BP]) 1 milligram (mg-unit measurement) intravenous (IV-into the vein) should be given every 3 mins.

A follow-up concurrent interview and record review, on March 29, 2022, at 10:45 AM, with RN 3 and the DON 1, Patient 1's "Code Blue Sheet," dated March 11, 2021, at 6:46 PM, was reviewed. The "Code Blue Sheet" indicated as follow:

6:46 PM: Sinus bradycardia (SB-low heart rate with normal rate for adult ranges from 60 to 100)
6:54 PM: no pulse, CPR initiated, and Epinephrine given
6:57 PM: CPR continued, and Epinephrine given
6:58 PM: HR and BP presented

RN 3 stated, the HR and rhythm were not checked every 2 mins. RN 3 confirmed, the ACLS guideline was not followed during the code blue.

A follow-up concurrent interview and record reviewed, on March 29, 2022, at 10:50 AM, with RN 3 and the DON 1, Patient 1's "Code Blue Sheet," dated March 11, 2021, at 8:49 PM, was reviewed. The "Code Blue Sheet" indicated as follow:

8:49 PM: Line across rhythm, with BP presented
8:50 PM: Line across rhythm and BP, Epinephrine given
8:51 PM: Heart rhythm as Pulseless Electrical Activity (PEA-abnormal heart rhythm without heart rate), CPR continued
8:52 PM: Line across rhythm and BP, Epinephrine given
8:53 PM: HR and BP presented

The DON 1 stated, the line across rhythm was not an acceptable documentation. The DON 1 further stated, the line across could also mean the heart rhythm were not checked during the code. The DON 1 confirmed, the ACLS guideline was not followed during the code blue.

During an interview, on March 30, 2022, at 2:20 AM, in the DQM's office, with the DQM, the DQM verified, the RRT or the code blue team was not called for the first code blue, on March 11, 2021, at 6:46 PM. The DQM confirmed, the unit nursing staff was not aware of Patient 1's heart rate, did not check on Patient 1, and did not initiated CPR or started the code blue documentation. The DQM verified, there was a time discrepancy of about five mins between a monitor technician's clock in the ICU and Patient 1's room that could not be accounted for in the first code blue documentation.

A review of the facility P&P titled, "Core: Emergency Care," release date June 2020, indicated as follow:

"Purpose: This policy establishes guidelines to manage emergency services for patients in a facility without emergency department services. This policy applies to all departments of the hospital.
Policy: ...Emergency care is provided to the patient by ACLS certified staff members, to include a physician provider whether in person or via telemedicine ...When a patient requires emergency interventions which include resuscitation, current ACLS guidelines are initiated until the time a physician assumes medical direction of the emergency care ...The components used to evaluate the effectiveness of the provision of emergency services performed include: ... appropriate use of current ACLS standards, evaluation of performance of care during emergency events including use of appropriate escalation procedures and complete documentation, and ensuring evaluation of capability and capacity of receiving facility prior to transfer ..."

Based on observation, interview, and record review, the facility failed to ensure the nursing staff administered medications as ordered and followed the acceptable standards of practice during medication administration when:

1. The nursing staff administered Hydromorphone (Dilaudid-medication to treat pain) faster than the recommended administration rate for one of 31 sampled patients (Patient 5).

2. The nursing staff administered Haloperidol (Haldol-medication to treat mental disorder) with a narrow time between two doses for one of 31 sampled patients (Patient 30).

3. The nursing staff did not assess patients' condition as ordered before and/or after as needed (PRN) medications administration for two of 31 sampled patients (Patient 12 and 13).

4. The nursing staff administered Dilaudid and Hydrocodone (medication to treat pain) medications for a wrong pain indication level as ordered without any physician's notification for other alternative medications for two of 31 sampled patients (Patient 5 and 13).

5. The nursing staff administered Dilaudid and Lorazepam (medication to treat anxiety) for a wrong indication not ordered by the physician for two of 31 sampled patients (Patient 5 and 20).

These failures had the potential to cause adverse health outcomes such as serious cardiac (heart) condition, preventable medication errors, inadequate patient monitoring, ineffective pain management, unrelieved pain and unnecessary medication use which could negatively affect Patients' health and safety with unsafe medication administration and could prolonged hospitalization, and/or lead up to death.

Findings:

1. During a review of Patient 5's "History and Physical (H&P)," dated February 9, 2022, the H&P indicated, Patient 5 was admitted into the facility with the diagnoses including sepsis (severe infection), colon cancer, and status post abdominal surgery.

A review of Patient 5's "Physician Order," for Dilaudid, dated March 26, 2022, at 1:57 PM, indicated, Dilaudid 0.5 milligram (mg-unit dosing of medication) intravenous (IV-into the vein) was ordered to be administered for moderate pain level of five (5) to six (6) (pain scale to evaluate pain level of patients, 0 signifies no pain and 10 signifies the more severe pain) PRN every three hours.

During an observation for medication pass, on March 28, 2022, at 10:05 AM, in Patient 5's room, Registered Nurse 1 (RN 1) was observed administering Dilaudid 0.5 mg IV to patient's right arm over 30 seconds.

During an interview, on March 28, 2022, at 10:15 AM, RN 1 stated an IV Dilaudid should be administered slow at least two minutes. RN 1 further stated, "I know I gave a little too fast." RN 1 confirmed, she did not administer a dose of IV Dilaudid 0.5 mg appropriately in accordance with medication administration time recommended.

A review of the facility's policies and procedures (P&P) titled, "Core: Administration of Medications via Injection," release date June 2020, indicated as follow:

"Purpose: This procedure establishes a system by which medications will be administered to patients' safety, accurately, and efficient by qualified personnel ...
Procedure ...
IV Push (pushing medication IV) ...
8. Administer IV Push medications no faster than 1 ml (milliliter-dosing unit of medication) per minute or slower if recommended by the drug reference or physician order. EXCEPTION: Medications being given during a Code situation ..."

2. During a review of Patient 30's H&P, dated December 19, 2021, the H&P indicated, Patient 30 was admitted to the facility with diagnoses including bowel perforation (a hole in the small intestine or colon), abdominal wound, and malnutrition.

A review of Patient 12's "Physician Order," for Haldol, dated March 9, 2022, at 11:34 AM, indicated, Haldol two (2) mg by mouth (PO) was order to be given every two hours PRN for agitation.

During an interview, on March 30, 2022, at 10:20 AM, in the Chief Operating Officer (COO)'s office, with the Director of Pharmacy (DOP) and the COO, the DOP stated, Haldol is not a narcotic and pharmacy does not track the dispense of Haldol. The DOP further stated, she was unable to verify the dispense and administration of Haldol for Patient 30.

A follow-up concurrent interview and record review, on March 30, 2022, at 10:23 AM, with the DOP and the COO, Patient 30's "Medication Administration Record (MAR)," dated March 9, 2022, through March 30, 2022, was reviewed. The MAR indicated as follow:

On March 26, 2022, at 6:11 PM: 2 mg of Haldol given
On March 26, 2022, at 6:39 PM: 2 mg of Haldol given (28 minutes from the last dose)

The DOP confirmed, Haldol was given 28 minutes apart between two doses. The DOP stated, the nursing staff did not give Haldol as ordered PRN every two hours.

A follow-up interview, on March 30, 2022, at 10:25 AM, with the DOP and the COO, the COO stated, the nursing staff were educated to document medication administration in real time but "it's not always happened." The COO further stated, it might be the "miscommunication" between the nursing staff and "hope it's not a double dose" on medication for Patient 30. The COO confirmed, the MAR showed Haldol was given with a narrow time between two doses.

A review of the facility P&P titled, "Core: Administration of Medications via Injection," release date June 2020, indicated as follow:

"Purpose: This procedure establishes a system by which medications will be administered to patients' safety, accurately, and efficient by qualified personnel ...
Procedure ...
1. General Guidelines for Administration of Medication ...
Documentation
b. The 7 "R's" of administering medications will be followed with each medication administration:
i. "Right" patient
ii. "Right" medication
iii. "Right" dose
iv. "Right" time
v. "Right" route
vi. "Right" reason
vii. "Right" documentation ..."

3a. During a review of Patient 12's H&P, dated February 23, 2022, the H&P indicated, Patient 12 was admitted into the facility with the diagnoses including respiratory failure (a condition when lungs cannot get enough oxygen), pneumonia (respiratory infection), and congestive heart failure (a condition that affects the pumping power of the heart muscles).

A review of Patient 12's "Physician Order," for Alprazolam (medication to treat anxiety), dated March 26, 2022, at 8:52 PM, indicated, Alprazolam one (1) mg tablet PO was order to be given every eight hours PRN for severe anxiety.

During a concurrent interview and record review, on March 29, 2022, at 4:20 PM, in the Director of Quality Management (DQM)'s office, with the COO, Patient 12's MAR, for Alprazolam, dated March 26, 2022, through March 29, 2022, was reviewed. The MAR indicated as follow:

On March 27, 2022, at 2:08 PM: no reassessment after medication administration
On March 28, 2022, at 8:39 AM: no assessment before medication administration

The COO stated she was aware the facility has been having problem with assessing patient before and/or after medication administration. The COO further stated, the nursing staff should assess patient before medication administration to see if the medication would be appropriate for the patient's condition and should assess patient after medication administration to determine the effectiveness of medication. The COO confirmed, the nursing staff did not properly assess Patient 12's condition before and/or after Alprazolam's administration.

A review of the facility P&P titled, "Core: Interdisciplinary Assessment and Re-Assessment," release date June 2021, indicated as follow:

"Purpose: This procedure establishes guidelines to assure: ...
5. To determine the appropriate care, treatment and services to meet the patient's needs during hospitalization.
Policy: The policy of [Hospital Name] are to ensure the following:
1. All patients will have an initial assessment and appropriate follow up assessments based upon identified patient-specific needs, including physical and psychosocial needs.
2. The goal of the Assessment/Reassessment process is to provide an interdisciplinary approach for the assessment and ongoing reassessment of individual patient care needs and for planning and implementing patient specific intervention ...
Procedure ...
3. Nursing department ...
g. Patient reassessment is based on but not limited to the following:
i. To evaluate patient response to care, treatment, and services
ii. To respond to a significant change in status and/or diagnosis or condition ..."

3b. During a review of Patient 13's H&P, dated January 20, 2022, the H&P indicated, Patient 13 was admitted into the facility with the diagnoses including respiratory failure, traumatic brain injury (brain dysfunction by a blow to the head), and quadriplegia (loss of use of both arms and legs).

A review of Patient 13's "Physician Order," for Hydrocodone 5 mg/Acetaminophen 325 mg (Norco-a combination of medications to treat pain), dated February 15, 2022, at 2:20 PM, indicated, Norco one (1) tablet PO was ordered to be administered for moderate pain level of five (5) to six (6) PRN every four hours.

During a concurrent interview and record review, on March 30, 2022, at 9:45 AM, in the COO's office, with the COO, Patient 13's MAR, for Norco, dated February 15, 2022, through March 19, 2022, was reviewed. The MAR indicated as follow:

On March 10, 2022, at 9:57 AM: no assessment before medication administration
On March 16, 2022, at 10:11 PM: no pain level and no reassessment after medication administration

The COO stated she was aware the facility has been having problem with the pain assessment. The COO further stated, the nursing staff should assess patients' pain before and after pain medication administration. The COO confirmed, the nursing staff did not properly assess pain before and after Norco's administration.

A review of the facility P&P titled, "Core: Pain Management Plan," release date June 2020, indicated as follow:

"Purpose: to establish an organized approach for caregivers to assess and mange patient's pain. The Pain Management Plan delineates the necessary assessments, interventions, monitoring, and patient/family education to promote effective pain relief.
Policy
1. The policy of [Hospital Name] is to ensure safe and effective practice in pain assessment, pain management, and safe opioid prescribing through the use of the Pain Management Plan ...
Procedure
1. Assessments of Patients
a. The Registered Nurse performs a pain assessment during the patient admission assessment. Ongoing pain assessments and reassessments are performed by licensed nurses at least every shift, when a patient complains of pain and after an analgesic is given to determine effectiveness of the analgesic. Each pain assessment and reassessment will be documented in the patient medical record ..."

4a. During a review of Patient 5's H&P, dated February 9, 2022, the H&P indicated, Patient 5 was admitted into the facility with the diagnoses including sepsis, colon cancer, and status post abdominal surgery.

A review of Patient 5's "Physician Order," for Dilaudid, dated March 26, 2022, at 1:57 PM, indicated, Dilaudid 0.5 mg IV was ordered to be administered for moderate pain level of five (5) to six (6) PRN every three hours.

During a concurrent interview and record review, on March 29, 2022, at 8:25 AM, in the conference room, with the Director of Nursing 1 (DON 1), Patient 5's MAR, for Dilaudid, dated March 26, 2022, through March 28, 2022, was reviewed. The MAR indicated as follow:

On March 27, 2022, at 2:25 AM: given for pain scale of "8"

The DON 1 stated the nursing staff was given Dilaudid for the wrong pain indication level. The DON 1 confirmed, the nursing staff did not follow the intended medication ordered to treat moderate pain. The DON 1 stated, he was unable to provide any document to indicate the physician's notification or request for an appropriate medication to treat the assessed pain level.

A follow-up interview, on March 29, 2022, at 8:45 AM, with the DON 1, stated, medication should be given as prescribed, and the nursing staff should verify the physician's order before medication administration. The DON 1 further stated, the physician should be notified if patients required other alternative medications as appropriate.

A review of the facility P&P titled, "Core: Pain Management Plan," release date June 2020, indicated as follow:

"Purpose: to establish an organized approach for caregivers to assess and mange patient's pain. The Pain Management Plan delineates the necessary assessments, interventions, monitoring, and patient/family education to promote effective pain relief.
Policy
1. The policy of [Hospital Name] is to ensure safe and effective practice in pain assessment, pain management, and safe opioid prescribing through the use of the Pain Management Plan ..."

A review of the facility P&P titled, "Core: Administration of Medications via Injection," release date June 2020, indicated as follow:

"Purpose: This procedure establishes a system by which medications will be administered to patients' safety, accurately, and efficient by qualified personnel ...
Procedure ...
1. General Guidelines for Administration of Medication ...
Documentation
b. The 7 "R's" of administering medications will be followed with each medication administration:
i. "Right" patient
ii. "Right" medication
iii. "Right" dose
iv. "Right" time
v. "Right" route
vi. "Right" reason
vii. "Right" documentation ..."

4b. During a review of Patient 13's H&P, dated January 20, 2022, the H&P indicated, Patient 13 was admitted into the facility with the diagnoses including respiratory failure, traumatic brain injury, and quadriplegia.

During an interview, on March 29, 2022, at 8:45 AM, in the conference room, with the DON 1, the DON 1 stated, medication should be given as prescribed, and the nursing staff should verify the physician's order before medication administration. The DON 1 further stated, the physician should be notified if patients required other alternative medications as appropriate.

A review of Patient 13's "Physician Order," for Hydrocodone 5 mg/Acetaminophen 325 mg (Norco), dated February 15, 2022, at 2:20 PM, indicated, Norco one (1) tablet PO was ordered to be administered for moderate pain level of five (5) to six (6) PRN every four hours.

During a concurrent interview and record review, on March 30, 2022, at 9:45 AM, in the COO's office, with the COO, Patient 13's MAR, for Norco, dated February 15, 2022, through March 19, 2022, was reviewed. The MAR indicated as follow:

On February 19, 2022, at 9:15 AM: given for pain level of "7"
On March 3, 2022, at 10:44 PM: given for pain level of "7"
On March 11, 2022, at 8:31 AM: given for pain level of "7"

The COO stated the nursing staff was not given Norco appropriately as indicated. The COO further stated, the nursing staff should notify the primary physician to request for an appropriate medication to treat the assessed pain level.

A review of the facility P&P titled, "Core: Pain Management Plan," release date June 2020, indicated as follow:

"Purpose: to establish an organized approach for caregivers to assess and mange patient's pain. The Pain Management Plan delineates the necessary assessments, interventions, monitoring, and patient/family education to promote effective pain relief.
Policy
1. The policy of [Hospital Name] is to ensure safe and effective practice in pain assessment, pain management, and safe opioid prescribing through the use of the Pain Management Plan ..."

A review of the facility P&P titled, "Core: Administration of Medications via Injection," release date June 2020, indicated as follow:

"Purpose: This procedure establishes a system by which medications will be administered to patients' safety, accurately, and efficient by qualified personnel ...
Procedure ...
1. General Guidelines for Administration of Medication ...
Documentation
b. The 7 "R's" of administering medications will be followed with each medication administration:
i. "Right" patient
ii. "Right" medication
iii. "Right" dose
iv. "Right" time
v. "Right" route
vi. "Right" reason
vii. "Right" documentation ..."

5a. During a review of Patient 5's H&P, dated February 9, 2022, the H&P indicated, Patient 5 was admitted into the facility with the diagnoses including sepsis, colon cancer, and status post abdominal surgery.

A review of Patient 5's "Physician Order," for Dilaudid, dated March 26, 2022, at 1:57 PM, indicated, Dilaudid 0.5 mg IV was ordered to be administered for moderate pain level of five (5) to six (6) PRN every three hours.

During a concurrent interview and record review, on March 29, 2022, at 8:30 AM, in the conference room, with the DON 1, Patient 5's MAR, for Dilaudid, dated March 26, 2022, through March 28, 2022, was reviewed. The MAR indicated as follow:

On March 27, 2022, at 10:30 PM: given for "agitated"
On March 28, 2022, at 9:20 PM: given for "restless"

The DON 1 stated the nursing staff was given Dilaudid for the wrong reason of restlessness and agitation. The DON 1 further stated, the nursing staff did not follow the intended medication ordered to treat moderate pain.

A follow-up interview, on March 29, 2022, at 8:45 AM, with the DON 1, stated, medication should be given as prescribed, and the nursing staff should verify the physician's order before medication administration. The DON 1 further stated, the physician should be notified if patients required other alternative medications as appropriate.

A review of the facility P&P titled, "Core: Administration of Medications via Infection," release date June 2020, indicated as follow:

"Purpose: This procedure establishes a system by which medications will be administered to patients' safety, accurately, and efficient by qualified personnel ...
Procedure ...
1. General Guidelines for Administration of Medication ...
b. The 7 "R's" of administering medications will be followed with each medication administration:
i. "Right" patient
ii. "Right" medication
iii. "Right" dose
iv. "Right" time
v. "Right" route
vi. "Right" reason
vii. "Right" documentation ..."


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5b. A review of Patient 20's H&P, dated February 12, 2022, indicated, Patient 20 was admitted with a diagnosis of respiratory failure and on a ventilator (machine to assist with breathing) via tracheostomy (trach - a tube placed into the trachea via the neck to assist with breathing).

A review of Patient 20's MAR for Lorazepam, indicated, "Lorazepam (Ativan): IV push inj (injection - liquid medication given into the body using a needle and syringe), 2 (two) mg, Renew start 03/14/22 (March 14, 2022) 15:15 (3:15 PM), q6h (every six hours), prn seizures (a brain disorder that can cause changes in behavior, movement, or feelings), stop after 30 (thirty) days, renewable."

During a concurrent interview and record review, on March 30, 2022, at 3 PM, with the DON 1, Patient 20's MAR, for Lorazepam, dated March 10, 2022, through March 19, 2022, was reviewed. The MAR indicated as follow:

On March 17, 2022, at 2:06 AM: given for blood pressure (BP) of 136/87 and heart rate (HR) of 88 beats per minute.
On March 17, 2022, at 2:36 AM: Indicated the medication was "very effective" and Patient 20 was "resting and calm."
On March 19, 2022, at 2:53 AM: given for reason "pt (patient) is anxious."
On March 19, 2022, at 4:42 AM: Indicated the medication was "effective."
On March 19, 2022, at 11:30 AM: given for reason "patient restless."
On March 19, 2022, at 12:00 PM: Indicated the medication was "effective" and "pt (patient) calm."

The DON 1 stated, Patient 20 was inappropriately given Lorazepam 2 mg for restlessness and pulling at his trach and not for seizures. The DON 1 further stated, the nurses should have given the lower dose of lorazepam (0.5 mg was actual dose ordered as needed for moderate anxiety) or called the physician to get a new order.

A review of the facility P&P titled, "Core: Administration of Medications via Infection," release date June 2020, indicated as follow:

"Purpose: This procedure establishes a system by which medications will be administered to patients' safety, accurately, and efficient by qualified personnel ...
Procedure ...
1. General Guidelines for Administration of Medication ...
b. The 7 "R's" of administering medications will be followed with each medication administration:
i. "Right" patient
ii. "Right" medication
iii. "Right" dose
iv. "Right" time
v. "Right" route
vi. "Right" reason
vii. "Right" documentation ..."

Based on interview and record review, the facility failed to ensure the nursing staff monitored the effect of medication on patients after intravenous (IV-into the vein) medication administration when the nursing staff did not monitor patients' blood pressure after IV Norepinephrine (Levophed-medication to increase blood pressure) were given to two of 31 sampled patients (Patient 1 and 4).

This failure had the potential to negatively impact on the drug's intended therapeutic effect, which could negatively affect Patients' health and safety without proper monitoring and could lead up to death.

Findings:

a. During a review of Patient 1's "History and Physical (H&P)," dated January 17, 2021, the H&P indicated, Patient 1 was admitted to the facility with diagnoses which included sepsis (severe infection), pneumonia (respiratory infection), encephalopathy (a condition of brain damage), and acute renal failure (a condition when kidneys do not work normally).

During an interview, on March 29, 2022, at 10:55 AM, in the conference room, with Registered Nurse 3 (RN 3), RN 3 stated, the IV Levophed would be administered as the physician's order. RN 3 further stated, patients would need to be monitored every five minutes until the blood pressure goal is met, be monitored every 15 minutes for one hour and hourly thereafter.

A review of Patient 1's "Physician Orders," Levophed, dated March 11, 2021, at 8:33 PM, indicated, started at 5 microgram/minute (mcg/min-unit infusion rate), and titrate (adjust) by 2 mcg/min every five minutes to keep mean arterial pressure (MAP-blood pressure) above 60.

A follow-up concurrent interview and record review, on March 29, 2022, at 11 AM, with RN 3, Patient 1's "Code Blue Sheet," dated March 11, 2021, at 8:49 PM and "Vasoactive (substance that affect blood pressure) Infusion Flowsheet" for Levophed, dated March 11, 2021, were reviewed. The "Vasoactive Infusion Flowsheet" showed, Levophed was started, on March 11, 2021, at 8:50 PM, at 10 mcg/min with the comment initiated during the code blue and there was no indication the starting of Levophed during the code blue. RN 3 stated, the nursing staff did not follow the physician order when starting Levophed.

A follow-up concurrent interview and record review, on March 29, 2022, at 11:05 AM, with RN 3, Patient 1's "Vasoactive Infusion Flowsheet" for Levophed, dated March 12, 2021, was reviewed. The "Vasoactive Infusion Flowsheet" for Levophed indicated as follow:

at 8:00 PM: MAP 79, titrated Levophed from 3 mcg/min to 2 mcg/min
at 8:30 PM: MAP 77, titrated Levophed from 2 mcg/min to 1 mcg/min
at 9:00 PM: recheck MAP 72
at 9:30 PM: recheck MAP 71

RN 3 stated, the nursing staff did not follow the physician order when titrating Levophed. RN 3 further stated, the nursing staff did not follow the facility's policies and procedures (P&P) in monitoring Patient 1's blood pressure after titrating Levophed.

A review of the facility's P&P titled, "Core: Vasoactive Infusions," release date June 2020, indicated as follow:

"Purpose: this policy is intended to define and standardize the administration, monitoring, and documentation processes for vasoactive medications, to ensure patient safety and maximize positive patient outcomes; and delineate the responsibilities of the nurse in the administration, monitoring, and documentation of vasoactive infusions.
Policy: the policy of [Hospital Name] is to ensure the following: ...
12. Vasoactive infusions will be administered at the does prescribed. Infusions may be titrated for the desired effect as stated and ordered by the Prescriber. A Vasoactive drug will not be titrated above the recommended maximum dose. Dose titration will be based on an individual patient's clinical status and predefined hemodynamic goals ...
15. When titrating vital signs will be monitored every 5 minutes until blood pressure is stabilized (hemodynamic goals are met).
16. When titrating the nurse will document the dose infusing every 5 minutes with associated vital signs.
17. Once hemodynamic goals are met; vital signs will be monitored and documented every 15 minutes for one hour.
18. Thereafter at a minimum, vital signs will be monitored and documented every hour during vasoactive infusion unless otherwise ordered by the prescriber ..."

b. During a review of Patient 4's H&P, dated January 20, 2022, the H&P indicated, Patient 4 was admitted into the facility with diagnoses including respiratory failure, and end stage renal disease (ESRD-a condition that kidney lost function) on hemodialysis (a process using a special machine to clean blood for patient with kidney problem).

During an interview, on March 29, 2022, at 10:55 AM, in the conference room, with RN 3, RN 3 stated, the IV Levophed would be administered as the physician's order. RN 3 further stated, patients would need to be monitored every five minutes until the blood pressure goal is met, be monitored every 15 minutes for one hour and hourly thereafter.

A review of Patient 4's "Physician Orders," Levophed, dated January 20, 2022, at 1:11 AM, indicated, started at 8 mcg/min, and titrate by 2 mcg/min every five minutes to keep systolic blood pressure (SBP) above 90.

A follow-up concurrent interview and record review, on March 29, 2022, at 11:10 AM, with RN 3, Patient 4's "Vasoactive Infusion Flowsheet" for Levophed, dated January 20, 2022, was reviewed. The "Vasoactive Infusion Flowsheet" for Levophed indicated as follows:

at 1:30 AM: SBP 77, titrated Levophed from 14 mcg/min to 15 mcg/min
at 1:45 AM: recheck SBP 92
at 9:15 AM: SBP 69, titrated Levophed from 15 mcg/min to 17 mcg/min
at 10:00 AM: recheck SBP 135

RN 3 stated, the nursing staff did not follow the physician order when titrating Levophed. RN 3 further stated, the nursing staff did not follow the facility's P&P in monitoring Patient 4's blood pressure after titrating Levophed.

A review of the facility's P&P titled, "Core: Vasoactive Infusions," release date June 2020, indicated as follow:

"Purpose: this policy is intended to define and standardize the administration, monitoring, and documentation processes for vasoactive medications, to ensure patient safety and maximize positive patient outcomes; and delineate the responsibilities of the nurse in the administration, monitoring, and documentation of vasoactive infusions.
Policy: the policy of [Hospital Name] is to ensure the following: ...
12. Vasoactive infusions will be administered at the does prescribed. Infusions may be titrated for the desired effect as stated and ordered by the Prescriber. A Vasoactive drug will not be titrated above the recommended maximum dose. Dose titration will be based on an individual patient's clinical status and predefined hemodynamic goals ...
15. When titrating vital signs will be monitored every 5 minutes until blood pressure is stabilized (hemodynamic goals are met).
16. When titrating the nurse will document the dose infusing every 5 minutes with associated vital signs.
17. Once hemodynamic goals are met; vital signs will be monitored and documented every 15 minutes for one hour.
18. Thereafter at a minimum, vital signs will be monitored and documented every hour during vasoactive infusion unless otherwise ordered by the prescriber ..."